l1ttle_0ne
Guru
I'm having a problem with a diagnosis for this procedure. Our physician put the diagnosis as appendicitis. However the pathology shows there was nothing wrong with the appendix. There is nothing noted on the H&P for that day as to the symptoms. There is an office visit dictation from the week prior that states he's been having chronic left lower quadrant pain. This was an out patient procedure. I'm confused as to what diagnosis to use since there was no appendicitis. Can anyone help?!?
Preoperative Diagnosis: Appendicitis
Postoperative Diagnosis: same
Procedure: Laparoscopic Appendectomy
Surgeon:
Findings:
The appendix was located in the peritoneal position. There was an enlarged, long appendix with a non-inflammed mesentery.
Procedure:
The patient was taken to the operating room and given general anesthetic and perioperative antibiotics. The abdomen was prepped and draped in the usual sterile manner. Access was obtained via Hasson technique at the umbilicus. A 12mm trocar was placed and pneumperitoneum was obtained. The was followed by a 5mm suprapubic port (4cm from pubic bone) and a 5mm LLQ port under direct visualizaiton. The appendix was mobilized medially with blunt and sharp dissection. The mesentery of the appendix was transected with an Endo-GIA Vascular stapler. Following this the appendiceal base was transected with a Endo-GIA vascular load as well. The appendix was the removed at the umbilicus via an endobag. The staple line was inspected and found to be hemostatic. The fascia at the umbilicus was closed with 0-vicryl sutures. The skin closed with 4-0 Monocryl subcuticular sutures. Sterile dressings were applied. The patient left the operating room in good condition. The estimated blood loss was 5 mL.
Preoperative Diagnosis: Appendicitis
Postoperative Diagnosis: same
Procedure: Laparoscopic Appendectomy
Surgeon:
Findings:
The appendix was located in the peritoneal position. There was an enlarged, long appendix with a non-inflammed mesentery.
Procedure:
The patient was taken to the operating room and given general anesthetic and perioperative antibiotics. The abdomen was prepped and draped in the usual sterile manner. Access was obtained via Hasson technique at the umbilicus. A 12mm trocar was placed and pneumperitoneum was obtained. The was followed by a 5mm suprapubic port (4cm from pubic bone) and a 5mm LLQ port under direct visualizaiton. The appendix was mobilized medially with blunt and sharp dissection. The mesentery of the appendix was transected with an Endo-GIA Vascular stapler. Following this the appendiceal base was transected with a Endo-GIA vascular load as well. The appendix was the removed at the umbilicus via an endobag. The staple line was inspected and found to be hemostatic. The fascia at the umbilicus was closed with 0-vicryl sutures. The skin closed with 4-0 Monocryl subcuticular sutures. Sterile dressings were applied. The patient left the operating room in good condition. The estimated blood loss was 5 mL.